Cost‐effectiveness analysis of antiviral treatment in liver transplant recipients with HCV infection

Within 5–10 years, 20–40% of hepatitis C virus (HCV)‐infected liver transplant recipients can be expected to develop cirrhosis. Here, cost‐effectiveness of antiviral therapy was assessed. A Markov model was developed to simulate disease progression and calculate outcome and costs of treatment. In the baseline analysis, Peg‐IFN/RBV treatment prevented organ loss/death, gained quality‐adjusted life‐years (QALYs) and undercut the limit of cost‐effectiveness of €50 000/QALY with an incremental cost‐effectiveness ratio of approximately €40 400/QALY and €21 000/QALY for HCV genotype 1 and 2/3 patients, respectively. Furthermore, sensitivity analysis testing modified model parameters according to extreme data described in the literature confirmed cost‐effectiveness for a lower or higher rate of fibrosis progression, increased non‐HCV‐related mortality, lower limits of utilities, a time horizon of 30 years, and additional costs in the year of death. On the other hand, cost‐effectiveness was lost for patients with genotype 1 in case of doubled antiviral or life‐time costs or an increased discount rate of 7%. New treatment strategies for HCV genotype 1 infected patients remained on the same level cost‐effective, if additional costs did not exceed €10 774 per 10% sustained virologic response gain. We conclude that Peg‐IFN/RBV treatment is cost‐effective post transplant. This may support treatment decision in individual cases.     

Cost‐effectiveness of pretransplant sofosbuvir for preventing recurrent hepatitis C virus infection after liver transplantation

There are reports of pretransplant sofosbuvir (SOF) plus ribavirin being effective in preventing recurrent hepatitis C virus (HCV) infection after liver transplantation (LT). The aim of this study was to assess the cost‐effectiveness of this strategy in the area served by the North Italy Transplant program. We retrospectively assessed the impact of HCV infection on post‐LT survival in 2376 consecutive adult patients (MELD ≤ 25, unknown genotype, period 2004–2009) and the prevalence costs of conventional standard of care (SOC) antiviral therapy (pegylated interferon plus ribavirin) after LT. A Markov model was developed to compare two strategies: 12–24 weeks of SOF+ ribavirin for pre‐LT anti‐HCV treatment versus on‐demand post‐LT SOC antiviral therapy. Among the 1794 patients undergoing LT, 860 (48%) were HCV+ and 50% of them were given SOC therapy after LT (mean cost of drugs and adverse effect management = 14 421€ per patient). HCV etiology had a strong impact on post‐LT survival (hazard ratio = 1.59, 95% CI = 1.22–2.09, P = 0.0007). After Monte Carlo simulation, pre‐LT SOF therapy showed a median survival benefit of 1.5 quality‐adjusted life years and an Incremental cost‐effectiveness ratio (ICER) of 30 663€/QALY, proving cost‐effective in our particular Italian scenario. The costs of SOF therapy, sustained viral response rate 12 weeks after LT, and recipient's age were the main ICER predictors at multivariate analysis. This study proposes a dynamic model based on real‐life data from northern Italy for adjusting the costs of pre‐LT direct‐acting antiviral therapies to the actual sustained virological response reached after LT.     

MR弥散峰度成像平均弥散率鉴别肝脏良、恶性病变:Meta分析

目的 采用Meta分析方法评估MR弥散峰度成像（DKI）平均弥散率（MD）鉴别肝脏良、恶性病变的效能。方法 于Pubmed、Cochrane Library、Embase、中国知网、维普和万方医学网中检索自建库至2021年3月20日以DKI参数MD值鉴别诊断肝脏良、恶性病变的相关文献;根据标准筛选文献,提取相关资料,以Stata 15.1和Meta-Disc 1.4软件分析MD值鉴别肝脏良、恶性病变的效能。结果 共纳入6篇文献,含493例患者、225个良性及362个恶性共587个病灶。汇总分析结果显示,肝脏恶性病变的MD值小于良性[标准均数差（SMD）=-1.31,95%CI（-1.54,-1.09）,Z=11.34,P<0.000 1];以MD值鉴别肝脏良、恶性病变的合并敏感度、特异度、阳性似然比、阴性似然比及诊断比值比分别为0.78[95%CI（0.74,0.82）]、0.73[95%CI（0.67,0.79）]、2.74[95%CI（2.22,3.39）]、0.31[95%CI（0.25,0.38）]及9.71[95%CI（6.63,14.21）];汇总受试者工作特征曲线的曲线下面积（AUC）为0.823 8。以MD值判断肝脏恶性病变为恶性的验后概率为76%,判断良性病变为恶性的验后概率为22%。结论 DKI的MD值鉴别肝脏良、恶性病变的效能较高。     

Systematic review of economic evaluations of laparoscopic surgery for colorectal cancer

Objective Colorectal cancer is one of the most common cancers and the standard surgical treatment for this cancer is open resection (OS), but laparoscopic surgery (LS) may be an alternative treatment. In 2000, a Health Technology Assessment (HTA) review found little evidence on costs and cost‐effectiveness in comparing the two methods. The evidence base has since expanded and this study systematically reviews the economic evaluations on the subject published since 2000. Method Systematic review of studies reporting costs and outcomes of LS vs OS for colorectal cancer. National Health Service Economic Evaluation Database (NHS EED) methods for abstract writing were followed. Studies were summarized and incremental cost‐effectiveness ratios (ICER) for common outcomes were calculated. Results Five studies met the inclusion criteria. LS generally had higher healthcare costs. Most studies reported longer operational time and shorter length of stay and similar long‐term outcomes with LS vs OS. Only one outcome, complications, was common across all studies but results lacked consistency (e.g. in two studies, OS was less costly but more effective; in another study, LS was less costly but more effective; and in the further two studies, LS could potentially be cost effective depending on the decision‐makers’ willingness to pay for the health gain). Conclusion The evidence on cost‐effectiveness is not consistent. LS was generally more costly than OS. However, the effectiveness data used in individual economic evaluation were imprecise and unreliable when compared with data from systematic reviews of effectiveness. Nevertheless, short‐term benefits of LS (e.g. shorter recovery) may make LS appear less costly when productivity gains are considered.     

A single‐center analysis of abdominal imaging in the evaluation of kidney transplant recipients

Many transplantation programs utilize noninvasive abdominal and pelvic imaging in the pre‐operative evaluation of recipient candidates. Practice patterns vary, and consensus guidelines addressing the risks and benefits of computed tomography (CT) and magnetic resonance imaging (MRI) in the pre‐transplant evaluation process do not currently exist. In this single‐center study, we examined the frequency, clinical significance, and associated costs of CT and MRI findings during the pre‐transplant evaluation of renal transplant recipients. A retrospective chart review of 3041 adult patients who underwent a CT/CTA or MRI/MRA of the abdomen and pelvis for pre‐transplant evaluation between 2005 and 2010 was performed. Pre‐transplant imaging with MRI offered a more sensitive evaluation in comparison with CT, with the notable exception of abnormalities in which calcium was detected. Patients imaged with CT had a significantly greater proportion of subsequent clinical actions arising from imaging findings. The total financial cost of MRI was greater than that of CT. No cases of nephrogenic systemic fibrosis (NSF) in patients who received MultiHance gadolinium contrast were reported. In conclusion, the risks, benefits, and costs of CT/CTA and MRI/MRA must be carefully considered to optimize the pre‐operative evaluation of renal transplant recipients.     

Cost‐effectiveness of a lifestyle modification program in long‐term survivors of hemopoietic stem cell transplantation

To evaluate the cost‐effectiveness of a lifestyle modification program targeting long‐term survivors of hematological malignancy treated with hemopoietic stem cell transplantation, a multistate life table Markov model was used to calculate health outcomes for both the intervention and no intervention. Cost per health‐adjusted life year (HALY) saved was reported for four scenarios: all participants with/without standard weight regain, and participants who at baseline were overweight with/without standard weight regain. The program recruited 53 participants and was associated with reductions in body weight of 2.2 kg and BMI 0.8 units on intervention completion (12 months) at a cost of $1233/participant. These adipose reductions were sustained and remained significant at 24 months. The incremental cost‐effectiveness ratios varied from $118 418 per HALY to dominant, depending on the weight regain assumption. The program may be cost‐effective in transplant survivors, with the results most sensitive to the weight regain assumption and intervention cost.     

Cost‐effectiveness of multi‐layered silicone foam dressings for prevention of sacral and heel pressure ulcers in high‐risk intensive care unit patients: An economic analysis of a randomised controlled trial

Pressure ulcer incidence is high in intensive care units. This causes a serious financial burden to healthcare systems. We evaluated the cost‐effectiveness of multi‐layered silicone foam dressings for prevention of sacral and heel pressure ulcers in addition to standard prevention in high‐risk intensive care units patients. A randomised controlled trial to assess the efficacy of multi‐layered silicone foam dressings to prevent the development of pressure ulcers on heels and sacrum among 422 intensive care unit patients was conducted. Direct costs for preventive dressings in the intervention group and costs for treatment of incident pressure ulcers in both groups were measured using a bottom‐up approach. A cost‐effectiveness analysis by calculating the incremental cost‐effectiveness ratio using different assumptions was performed. Additional dressing and labour costs of €150.81 (€116.45 heels; €34.36 sacrum) per patient occurred in the intervention group. Treatment costs were €569.49 in the control group and €134.88 in the intervention group. The incremental cost‐effectiveness ratio was €1945.30 per PU avoided (€8144.72 on heels; €701.54 sacrum) in the intervention group. We conclude that application of preventive dressings is cost‐effective for the sacral area, but only marginal on heels for critically ill patients.